NPIMap

Organization Active NPI

Keystone Pharmacy Inc

Doing business as Keystone Pharmacy

  • Compounding Pharmacy
  • Grand Rapids, MI
National Provider Identifier
1316049745
Registry record updated Mar 17, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Compounding PharmacyTaxonomy code 3336C0004X
License
5301007431 Issued in MI
Legal business name
KEYSTONE PHARMACY INC
Doing business as
Keystone Pharmacy
Practice address
4021 Cascade Rd SE
Grand Rapids, MI 49546-2177
Phone
(616) 974-9792
Fax
(616) 464-3469
NPI assigned
Sep 5, 2006
Last updated
Mar 17, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 17, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
David Miller, R.PH., PH.D.NPI 1245712116
Title
Owner
Phone
(616) 974-9792

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X
Compounding Pharmacy 3336C0004X 5301007431 MI Primary

Addresses

Primary practice location

4021 Cascade Rd SE
Grand Rapids, MI 49546-2177

Mailing address

4021 Cascade Rd SE
Grand Rapids, MI 49546-2177
Phone (616) 974-9792

Other identifiers 2

IdentifierTypeStateIssuer
2045985OtherPK
2369086MedicaidMI

Other names 1

  • KEYSTONE PHARMACY Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120209000733 MI Part B Supplier - Mass Immunization (Roster Biller Only) 2769649375 Practice locations: Grand Rapids, MI

National Provider Directory

National Provider Directory
Tax ID family
Keystone Pharmacy Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4021 Cascade Rd SE
Ste 5
Grand Rapids, MI 49546
Phone (616) 974-9792

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1157414400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1489708800000",
    "number": "1316049745",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4021 CASCADE RD SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495462177",
            "telephone_number": "616-974-9792",
            "fax_number": "616-464-3469"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4021 CASCADE RD SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495462177",
            "telephone_number": "616-974-9792",
            "fax_number": "616-464-3469"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KEYSTONE PHARMACY INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-05",
        "last_updated": "2017-03-17",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "616-974-9792",
        "authorized_official_credential": "R.PH., PH.D."
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0004X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Compounding Pharmacy",
            "state": "MI",
            "license": "5301007431",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2045985",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2369086",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KEYSTONE PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 17, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.